A5a Parental Consent Form_English Version

Appendix A-5a

Parental Consent

National Food Study Pilot

Agency: Economic Research Service

Contractor: Westat, Inc.

Parental Consent Form

OMB Control Number: xxxx-xxxx

Expiration Date: xx/xx/xxxx

You are being asked to allow your child to participate in the National Food Study (NFS) Pilot. Please read the following information carefully before you decide whether or not you consent to allow your child to participate.

Sponsor of Study: The study is sponsored by the U.S. Department of Agriculture (USDA) under the authority of United States Code Title 7 Section 2026 (a) (1). The study is conducted by Westat, an independent research firm.

Purpose of the study: This study will collect information to help USDA improve its programs and help to assure that all residents of the US have access to a healthy diet at affordable prices.

Procedures to follow: If you agree to your child participating, we will ask your child to keep track of the foods he or she gets for 7 days. We will also ask you to give your consent to minors accessing the web instrument to report for themselves. Alternatively, you can report for minors in your household. The study procedures for your child include:

1. Keep track of food and drinks purchased or obtained for free during the next 7 days. This includes scanning food items that your child brings into your home and reporting food items obtained and consumed outside your home. Your child’s smartphone or a scanner that can be connected to a computer to scan food items during the week will be used to scan food items. This may take about 25 minutes per day during the week.

2. Keep track of which meals and snacks your child has during the next 7 days. This may take each person about 3 minutes per day.

3. Complete a Recall Interview if selected. We will ask about the last two days your child tracked food and drinks. This may take each person about 20 minutes.

Incentives for participation: Each eligible child will receive $3 for every day that he or she reports food and drinks that he or she got or indicates that he or she did not get any food and drinks on a given day. Each eligible child can earn a maximum of $21 for completing the food log on all 7 days.

Voluntary participation: Taking part in the study is voluntary. If you choose to participate, your child can skip any question he or she does not want to answer or that makes him or her feel uncomfortable. Deciding to take part in the study or not, or withdrawing from the study, will not affect your eligibility for benefits or services received by anyone in your household—now or in the future. Each household member may decide to participate. Your household may participate even if some but not all members agree to participate.

Risks and Benefits: The risks are no greater than those ordinarily encountered in daily life. If you receive SNAP benefits (or food stamps), the study incentives will not affect your eligibility or benefit amount. There are no direct benefits to participating in this study.

Termination of participation: Your child may choose to withdraw from the study at any time. If your child withdraws before tracking foods for 7 days, he or she will receive only the study incentives for the period of his or her participation in the study. The study may use the data provided to us up to the time of withdrawal.

Statement of confidentiality: We are required by law (read box below) to use your information for statistical research only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you or your family without your consent.

Assurance of Confidentiality: All information which would permit identification of an individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only, will be used only by USDA staff, contractors, and agents authorized by USDA to perform statistical activities only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or establishment in accordance with the Confidential Information Protection and Statistical Efficiency Act (PL-107-347). By law, every employee as well as every agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.

If you have questions about this research, please contact Janice Machado, the Project Director at (301-294-2801; [email protected])

If you have questions about your rights and welfare as a research participant, please call the Westat Human Subjects Protections office at 1-888-920-7631. Please leave a message with your full name, mention that you are calling about the National Food Study, and leave a phone number beginning with the area code. Someone will return your call as soon as possible.

I read the information provided on this form. I voluntarily agree to allow my child to participate in this study.

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Printed Name of Child

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Signature of Parent/Legally Authorized Representative Date

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Printed Name of Parent/Legally Authorized Representative